Mental Health & Medicine

You may have stumbled across my website after learning about my arguments in mental health and medicine. Although most of my research is in academic political science, I have found that my book project and related work carry practical implications for these fields.

Perhaps the most important of which is that community and hospital psychiatry may have a complementary relationship -- contrary to the presumptions driving de-institutionalization. Mental health care, in addition, appears to require more public funds than other areas of health care.

Please see below for more information.

2021. Isabel M. Perera and Alex V. Barnard, "Myths of Mental Health: Revelations from a French-American Comparison," in Perspectives in Medicine and Biology [PDF]

Drawing on an analysis of the French mental health system, this essay examines four presumptions about mental health care dominant in the United States. Claims about 1) the required abolition of the hospital for psychiatric deinstitutionalization, 2) the substitutability of public and private financing, 3) the importance of a “dangerousness” criterion for involuntary commitment procedures, and 4) the need for an ever-expanding scope of care hold little weight when subjected to comparative scrutiny. We close by discussing the implications of these revelations for U.S. mental health care policy and ethics.

2021. Julia F. Lynch, Isabel M. Perera, and Theodore J. Iwashyna. "Scarce Resource Allocation in a Pandemic: A Protocol to Promote Equity, Timeliness, and Transparency" in Critical Care Explorations

Shortages of equipment, medication, and staff under coronavirus disease 2019 may force hospitals to make wrenching decisions. Although bioethical guidance is available, published procedures for decision-making processes to resolve the time-sensitive conflicts are rare. Failure to establish decision-making procedures before scarcities arise exposes clinicians to moral distress and potential legal liability, entrenches existing systemic biases, and leaves hospitals without processes to guarantee transparency and consistency in the application of ethical guidelines. Formal institutional processes can reduce the panic, inequity, and irresolution that arise from confronting ethical conflicts under duress. Drawing on expertise in critical care medicine, bioethics, and political science, we propose a decision-making protocol to ensure fairness in the resolution of conflict, timely decision-making, and accountability to improve system response.

2020. Isabel M. Perera, Two Dogmas of Mental Health Policy,” in the Health Affairs Blog; re-blogged by Health Policy$ense

As the presidential race heats up, candidates are weighing in on how they would reform the nation’s broken mental health system. Pundits have linked its flaws to a range of headline issues. Behavioral health care shortages purportedly exacerbate the increased frequency of mass gun violence, the negative effects of social media, and even the anxieties produced by the economic, environmental, and immigration landscape. The mental health system is far from the cause of those problems, but politicians (on both sides of the aisle) are rightly concerned about how to end the policy chaos that leaves millions of Americans untreated, and often homeless or incarcerated instead.

Many of these policy proposals, however, contain unexamined assumptions about our current system and how it operates. In previously published research in the Lancet Psychiatry and Psychiatric Services, I used cross-national data from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD) to examine the economic assumptions that guide mental health policy making and found reason to doubt two common beliefs: one, about the importance of private payers, and the other, about the relationship between inpatient and outpatient care.

2020. Isabel M. Perera,The Relationship between Hospital and Community Psychiatry: Complements, Not Substitutes?” in Psychiatric Services

Community-based psychiatric services are essential to mental health. For decades, researchers, advocates, and policy makers have presumed that expanding the supply of these services hinges on reducing the supply of hospital-based care. Cross-national data from the World Health Organization call this presumption into question. Community and hospital psychiatry appear to be complements, not substitutes.

2020. Isabel M. Perera and Sidney Tarrow. What America Got Wrong About COVID-19–and What We Can Learn from France and Italy," in Public Seminar

Institutional fragmentation and a lack of national solidarity have derailed the pandemic response.

2020. Stephen Allison, Tarun Bastiampillai, Jeffrey C.L. Looi, Simon Judkins, and Isabel M. Perera. "Emergency department–focused mental health policies for people with severe mental illness," in the Australian and New Zealand Journal of Psychiatry

The Australasian College for Emergency Medicine (ACEM) has released a major report on Australia’s mental health system: Nowhere to go: Why Australia’s health system results in people with mental illness getting ‘stuck’ in emergency departments. The report is significant for several reasons. First, ACEM joins the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in national advocacy for improved mental healthcare (Jenkins, 2019; Judkins et al., 2019). Second, the report presents a clear case for an emergency department (ED) focus in national mental health policymaking, along with well-defined outcome measures including ED length of stay (LOS). Finally, the report takes a balanced approach to community and hospital services: ‘ACEM will also continue to advocate for governments to increase the amount of inpatient mental health services and community mental health services to ensure that people with mental health needs have sufficient and equable access to appropriate services’ (ACEM Report, p. iii).

2019. Isabel M. Perera and Dominic A. Sisti, “Mass Shootings and Psychiatric Deinstitutionalization, Here and Abroad,” in the American Journal of Public Health [PDF]

Is deinstitutionalization to blame for the regularity of mass shootings in America? Deinstitutionalization occurred not only here but also across other high-income democracies. Major international organizations, such as the World Health Organization, have supported the reduction of hospital psychiatry. Comparing cross-national data of mass shootings—typically defined as four or more fatalities—with the decline of inpatient psychiatric capacity offers little evidence to support this association.

2019. Isabel M. Perera,Is Psychiatry Different? An Economic Perspective,” in the Lancet Psychiatry [PDF]

Compared with the general health system, the mental health system faces distinct challenges. Perennial flashpoints include issues of stigma, coercive treatment, and nosology, which generate heated ethical and policy debates. Often overlooked, however, is another characteristic of the mental health sector: its financial dependence on the public purse

2019. Aaron J. Glickman, Isabel M. Perera, and Dominic A. Sisti The Institutions for Mental Diseases Exclusion Rule is an Anachronism,” in The Regulatory Review

The time has come for repealing Medicaid’s Institutions for Mental Diseases Exclusion rule.

2019. Isabel M. Perera, “Mental health and politics since the eurozone crisis,” in European Psychiatry [PDF]

Some of the most immediate health effects of the 2008 economic crisis concerned the mind, not the body. Rates of generalized anxiety, chronic depression, and even suicide spiked in many European societies. This viewpoint highlights the role of mental health professionals in responding to this emergency, and argues that their sustained mobilization is necessary to its long-term resolution.

2013. “Health Effects of the Crisis in Southern Europe,” with Julia F. Lynch in the APSA European Politics and Society Newsletter (Summer, 11-14).